Consultant on Call

Brett Beckman, DVM, FAVD, Diplomate AVDC & AAPM Animal Emergency Center of Sandy Springs, Atlanta, Georgia Affiliated Veterinary Specialists, Orlando, Florida Florida Veterinary Dentistry & Oral , Punta Gorda, Florida

Gingival Hyperplasia

1 G PROFILE Calcium antagonism may play a role in aldo- Gingival hyperplasia in a cat sterone synthesis by increasing testosterone taking cyclosporine for feline Definition levels. 5 lymphocytic-plasmacytic gingivostomatitis. G Gingival hyperplasia is defined as an enlarge - G Studies have shown an increase in gingival ment of the gingiva that is noninflammatory, hyperplasia associated with testosterone injec - produced by factors other than local irritation, tions and a decrease in hyperplasia in castrated and the result of an increased number of cells. 1 dogs receiving oxodipine. 6 G Because gingival hyperplasia denotes a specific G In patients receiving cyclosporine, transglutamin - histologic diagnosis, clinicians must rule out ase levels are decreased in gingival tissue when other causes of with biop - calcium is not readily available, thereby decreas - sies of affected tissues. 2 A common example is ing apoptosis 7 (Figure 1) . gingival enlargement caused by local irritation or G In feline studies, cells resembling fibroblasts were . stimulated to proliferate with the administration of phenytoin; this process resulted in gingival Signalment enlargement. 8 Species . Seen more often in dogs than cats . Signs Breed predilection . Great Danes , collies , dalma - G Physical examination reveals solitary, multiple, or tians , and Doberman pinschers; boxers appear to be generalized enlargement of attached gingiva. overrepresented 3 G Inflammation may be secondary to periodontitis but is not responsible for primary enlargement in Causes gingival hyperplasia (see Definition ). G Idiopathic G upon probing is a good indicator of G Breed predisposition periodontal involvement. Tissue is generally firm G Medications to the touch. G Proliferation may become excessive and gingiva Pathophysiology may resemble an oral mass, resulting in mobil - G Drug-induced gingival hyperplasia appears to be ity upon manipulation. associated with alteration of calcium influx in gingival tissue. The exact mechanism of action has yet to be determined. 4 CONTINUES

Consultant on Call / NAVC Clinician’s Brief / January 2010 ...... 11 Consultant on Call CONTINUED

DIAGNOSIS Systemic Although multiple human diseases have been asso - Definitive Diagnosis ciated with gingival enlargement , systemic associa - G Definitive diagnosis can be made only by biopsy tions in dogs and cats have not been adequately and histopathologic examination . documented in the literature. G Gingival hyperplasia is noninflammatory, but can alter this condition Neoplasia G clinically and histologically. Any benign or malignant oral mass is a gingival enlargement that may resemble gingival hyper - Differential Diagnosis plasia. Biopsy must be done in these cases. G Gingival hyperplasia must be differentiated from Dental becomes important in differ - other forms of gingival enlargement. Acute and entiating malignant oral masses from hyperplasia. G chronic inflammation , generally associated with Productive tumors of and cysts may cause periodontal disease , can cause generalized or focal the appearance of hyperplasia by expanding gingival enlargement, which may then cause a beneath the attached gingiva. G hyperplastic appearance of the gingiva. A similar condition is commonly seen in cats with expansion of buccal bone secondary to peri - Medications odontal disease or root resorption associated with Medications in the following 3 categories share the resorptive disease . G mechanism of calcium antagonism , which is Gingival hyperplasia should not be confused thought to play a role in the hyperplastic process. with proliferative gingival lesions associated with G Immunosuppressants (especially cyclosporine): feline lymphocytic plasmacytic gingivostomatitis Have been known to produce gingival hyperpla - or tooth resorption. sia. 9 This condition has recently been recognized more frequently due to use of cyclosporine ther - TREATMENT apy for treating atopy in dogs and cats. G Calcium-channel blockers : Shown to produce Medical Extensive gingival hyper - G In 1 study, folate decreased gingival hyperplasia plasia in a dog (A) ; the gingival hyperplasia in dogs treated for cardiac same patient after gin - disease. 10 in humans and cats taking the anticonvulsant 13 givoplasty was performed G Anticonvulsants : Produce gingival hyperplasia in phenytoin. with a 15-scalpel blade 11,12 G The condition often resolves simply by with - and a 12-fluted carbide cats and dogs. burr (B) drawing medication, but this solution is often not feasible. 14 2

A B

12 ...... NAVC Clinician’s Brief / January 2010 / Consultant on Call Surgical G Surgical correction provides definitive pseudopocket removal and reestablishes normal gingival contour (Figure 2) . G Bulk removal of tissue is accomplished with scalpel excision. using a 12-fluted burr provides accurate contour (Figure 3) . Q The pocket depths and landmarks for excision are located with the aid of a and needle to provide bleeding points in the gingiva as a guide to excision. Q The periodontal probe is inserted into the pocket to measure depth. It is then removed and placed on the adjacent gingival epithe - lium. Q A needle then marks the pocket depth 2 mm 3 15 coronal to the actual depth of the pocket. 12-fluted carbide burr on a This ensures a final sulcus of 2 mm. MEDICATIONS high-speed dental handpiece Q A bevel incision is then made to this level at an angle of 45°. G Analgesic management is essential when gin - Q Once gingivoplasty removes the bulk of the givectomy or gingivoplasty is chosen to treat hyperplastic tissue, a 12-fluted carbide burr gingival hyperplasia. (which I prefer) or a diamond burr is used to G Premedication with analgesics is commonly used provide precise gingivoplasty to approximate before when surgical manipulation of the original contour of the gingiva. the oral cavity is imminent. G Electrosurgery and have been used to pro - G Regional nerve blocks are needed to ensure vide both bulk removal and contouring, but only immediate postoperative comfort and, most individuals with extensive experience should important, optimal anesthetic safety. consider use of those methods in lieu of the G Postoperative analgesics are indicated for 4 to 6 days. method described. m FIND o c

. MORE f

FOLLOW-UP e Client Education i in our r

G b Gingival hyperplasia and gingival overgrowth s Archives n

Patient Monitoring a

result in pseudopockets that trap debris and i c G Although postoperative complications are not i

plaque, commonly resulting in periodontal pock - n i l

eting. likely when scalpel and burr gin - c G Treatment involves recreating normal anatomy givoplasty are used, 7-day rechecks are advised. surgically; however, gingival hyperplasia not G If the operator chooses to use the more invasive associated with any specific cause, such as that techniques, follow-up should be at 7-day inter - seen in idiopathic breed-related hyperplasia, will vals for 3 to 4 weeks to ensure that there are no recur in most cases. signs of thermal damage. G The condition usually recurs many months to years later, but clients should be aware that Complications repeated gingivectomy or gingivoplasty may be G Complications generally arise only when laser required. surgery and electrosurgery are used for gingivec - tomy or gingivoplasty. G Proper settings, operator experience, and precise technique are paramount if these methods are chosen.

CONTINUES

Consultant on Call / NAVC Clinician’s Brief / January 2010 ...... 13 C o n s u l t a n t o n C a l l C ONT INUED

4 Thermal necrosis in a patient treated for gingi- val hyperplasia using radiosurgery. Generalized bone, soft tissue, and pulp necrosis resulted in multi- ple extractions.

G Thermal necrosis of gingival tissue, G Many cases do recur, however, and bone, and teeth can result when these surgical intervention may be required methods are used improperly (Figure 4). periodically to control the condition.

Future Follow-Up Cost Considerations G Annual or biannual examinations can be General anesthesia and analgesia are used to monitor for recurrence of hyper- required for surgical management. Sever- plastic tissue. ity of the condi- G Need for repeated surgery should be tion varies from determined according to the extent of focal, isolated Cost Key the changes. involvement to $ = < $100 generalized $$ = $100–$250 IN GENERAL hyperplasia. $$$ = $250–$500 Therefore, the $$$$ = $500–$1000 Prognosis cost of therapy $$$$$ = > $1000 G Prognosis for a reasonable interval of ranges from $$$ clinical resolution is excellent. to $$$$$.

TREATMENT AT A GLANCE

Medical G Create bleeding pockets with a G If possible, discontinue calcium- needle. channel blockers, anticonvulsants, or G Remove bulk gingiva with a scalpel. immunosuppressants. G Contour remaining gingiva with a 12- G Consider using folate supplementation, fluted carbide burr or diamond burr. which has been shown to decrease drug-induced gingival hyperplasia in humans. Postoperative G Provide analgesic management. G Recheck in 7 days. Surgical G Use annual or biannual examinations G Apply regional nerve blocks. to monitor for recurrence. G Measure pocket depths.

See Aids & Resources, back page, for references, suggested reading, and resources. Article archived on cliniciansbrief.com

14...... NAVC Clinician’s Brief / January 2010 / Consultant on Call